Financial Services Professionals

Application for Professional Liability Insurance

If you can respond "True" to all of the eligibility statements below, then you qualify
for the EZ Insurance Solutions Professional Liability Program.

Qualifying Questions

After the inquiry of all owners, partners and officers of the firm:

1
.
No firm member or employee is a licensed CPA.

TrueFalse

2
.
No firm member or employee is aware of any act, omission or fee dispute which might be expected to be the basis of a claim or suit against the firm, firm personnel, or the firm's predecessors in business.

TrueFalse

3a
.
Within the past 5 years, no firm member or employee has been the subject of any regulatory investigation or inquiry; suspended from practice; or charged, indicted, plead guilty or convicted of any felony charge.

TrueFalse

3b
.
No firm, its members or employees have had any disclosure events or reportable events on their respective Form U-4, U-5, U-6, or Form ADV or similar document.

TrueFalse

4
.
Within the past 5 years, the firm has not prepared any financial statements that have been used in any securities offerings whether public, private, registered, or unregistered.

TrueFalse

5
.
Within the past 5 years, no firm member or employee has had any professional liability insurance declined, canceled or non-renewed (Not applicable in Missouri).

TrueFalse

6
.
Within the past 5 years, the firm, its predecessors in business, and associated owners and employees have had no more than 2 claims including suits, settlements, arbitrations, and mediations.

TrueFalse

7
.
Within the past 5 years, the total amount paid or reserved on claims, settlements, and/or arbitrations against the firm, its predecessors in business, and associated owners and employees is no more than $10,000.

If you responded 'True' to all statements above,
you qualify for the Plan. Please complete the information requested and return it as soon as possible.
Once your application is received, we'll send you a quotation. If you do not qualify,
you can call Affinity Insurance Services toll-free at 1-866-225-8464 to speak to a representative about coverage options available to you.